Welcome to Episode 18 of Contain This, brought to you by the Indo-Pacific Centre for Health Security, hosted by Dr Lara Andrews.
Today on the show, Lara speaks to Gillian McKay and Matelita Seva-Cadravula, on the topic of sexual and reproductive health and rights during a health emergency.
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Contain This Team
Matelita SevaCadravula 00:00
Sex is not stopping just because we have COVID pandemic. Our clients, they still need to have contraceptives, they still need to prevent unwanted unplanned pregnancies. We and... gender-based violence, especially sexual gender-based violence - it's still happening, and we need to provide the services.
Dr Lara Andrews 00:25
Welcome to Contain This. I'm Dr Lara Andrews from the Indo Pacific Centre for Health Security. This week I talk with Fijian practitioner Matelita Seva-Cadravula, and UK-based researcher Gillian McKay to explore the issue of sexual reproductive health and rights during health emergencies.
Gillian is a nurse and global health researcher who is currently completing her doctorate in public health at the London School of Hygiene and Tropical Medicine. Gillian is reviewing family planning access and provision in the 2014 to 2016 West African Ebola outbreak. Last year, she worked in the Democratic Republic of Congo, helping the Ebola response in North Kivu.
Matelita is the executive director of the Reproductive and Family Health Association of Fiji. The association is the in-country partner for International Planned Parenthood Federation's humanitarian program, known as SPRINT, funded by the Australian Government.
Gillian, Matelita, welcome to Contain This. I might jump straight in Gillian and ask you what is so critical about sexual reproductive health and rights during health emergencies? Why is it so important?
Gillian McKay 01:36
Hey, thanks so much for the question. And so I mean, I think maybe it would help by starting by defining, what is sexual reproductive health and rights? And sexual productive health and rights includes a wide range of issues everywhere from HIV and sexual and reproductive, sexually transmitted infections, to maternal health, contraceptive and abortion access, prevention, and care for gender-based violence and so much more. So really, the intention of promoting and engaging with sexual reproductive health and rights inside and outside of health emergencies is to ensure that everyone in society has adequate support for equality for both women, men, boys, girls and non-binary people. So it's really about making sure everyone can live a healthy, safe, and just sexual reproductive life. And so let's let's think a little bit about what happens in a health emergency.
My background very much is in Ebola outbreaks. But I know that we'll have a conversation broader than that over the next little while. But let's imagine, say an outbreak of cholera or Ebola. So we know that what happens in these types of events is that there's both direct consequences and indirect consequences. So direct impacts for say, an outbreak of Ebola would be people who actually get Ebola, and unfortunately, either die from it or are made severely ill or ideally recover. Now, indirect impacts are related to what happens when the outbreak disrupts how society and systems function. This is really where sexual reproductive health and rights come in. So in the case of an outbreak, health systems and services are disrupted because there's a shift in focus. So we go from delivering routine health care is our main focus of health care of healthcare delivery, and that includes infectious disease, chronic disease, nutrition, etc, to stopping the spread of outbreaks. Now, this can result in unfortunately, loss of access to health care for all types of health care.
I'm going to bring an example in here. So some of the work that I did in Sierra Leone during the Ebola outbreak, there was the pregnant women would present themselves at a health care facility in labor ready to deliver their baby. But unfortunately, in the early days of the outbreak, many of those health care workers had been infected with Ebola while providing maternity care to these pregnant women or, and some of these pregnant women unfortunately had Ebola, so healthcare workers got sick, because they didn't have sufficient protective equipment. So you know, in the later days of the outbreak, when women would show up pregnant in labor ready to deliver health care workers would sometimes say look, I can't deliver your baby, because I don't have sufficient protective equipment. And so this is kind of looking at you know, that's just an example. But this shows that it's those broader indirect outbreak impacts that can cause direct results unfortunately on sexual reproductive health.
Dr Lara Andrews 04:27
Gillian, thank you for that. You raise some really interesting issues and your example is really pointed. Ma, I might turn to you listening to what Jillian has said how do you relate to this and these issues that she has raised from your perspective from your work in Fiji with the Fiji Reproductive and Family Health Association?
Matelita Seva-Cadravula 04:53
Thank you, Lara. In Fiji, we we do work around responding to humanitarian settings and also disasters, and crises that happened within Fiji and an example would be the response to tropical cyclone Harold that we just had this year. We respond to the affected population using the internationally recognized minimum initial service package known as the MISP. This is a set of six objectives of which for our clinical that are proven to reduce death and diseases, especially among women and goals. The floor for clinical activities include ensuring pregnant women have a safe environment to deliver their babies, that is the presence of a skilled birth attendant to deliver the baby. Secondly, preventing and responding to sexual and gender based violence. As we all know that gender based violence always increased in any humanitarian setting or emergency. Thirdly, the prevention of unintended pregnancies through access to contraception, and information and fourthly, reducing morbidity and mortality due to HIV and sexually transmitted infections. That means that one can get the medicine one needs to remain healthy, such as a anti-retroviral for a person living with HIV. We do this in humanitarian or emergency settings.
For example, this year, my home Fiji, and other countries in the Pacific experienced Tropical Cyclone Harold, this Category Four tropical cyclone made landfall into Fiji on the eighth of April, causing widespread destruction from winds, storm surges flash flooding and waves up to two meters. It badly affected the Candavu group of islands. So with assistance from the International Planned Parenthood Federation, IPPF and the Department of Foreign Affairs and Trade DFAT, we at the Reproductive and Family Health Association of Fiji was able to mount a humanitarian response for the 10,000 plus residents of Kadavu. So the organization assembled a team together that is able to ensure the delivery of all the necessery life-saving clinical activities I have just mentioned. So at the time, accessing villages by road was really limited. Hence the only way to access the 74 villages around Kadavu was mainly by boat. So once the team arrived, we had to travel by a small fiberglass boat to reach most of the villages of Kadavu Island sometimes in during rough seas. But we were able to deliver services to 67 villages, accessing nearly 2000 people on the island.
On that response, one of the beneficiaries that we spoke to in one of the villages that was badly affected and is also one of the biggest villages on Kadavu stated, I quote, "I was traumatized by the devastation caused by Tropical Cyclone Harold, because I had never seen anything like this before in my life". With the tears streaming down his face, the villager relived what he encountered, "My wife and I had to attend to the injured since the road was blocked by debris, before help would arrive. And I remember having to tuck an old man under our house, because his house had blown away. And I've been having trouble sleeping. And then your team arrived with counselling sessions and psycho-social support that my wife and I received. I'm now coming to terms with what happened. And so thankful that you came to the community, because I would have traveled to Vunisea, which will cost me $300 just to get to the hospital. And I thank you so much for thinking about us. And I will make sure that when I get into Suva I will visit your clinic." So those are some of the things that we do encounter and people become thankful and grateful for the response that we are able to carry out during emergencies. Thank you.
Dr Lara Andrews 09:40
Thank you for that, Ma. What a positive story about humanitarian response and how vital it is, in particular the psychosocial services and it's really good to hear that being emphasized. And Ma, you mentioned that during the response to Cyclone Harold, you were just to provide services to around about 10,000 people. I believe I read a statistic that says at any one time in a in a health emergency, there can be up to 20% of women who are pregnant. Did your team's experience particular challenges around maternal health in particularly the delivery of babies accessing supplies, safe places to have safe deliveries, as well as the delivery of other sexual reproductive health services? Would you be able to talk a little bit about that?
Matelita Seva-Cadravula 10:34
Thank you, Lara. One of the work we do is preventing unintended pregnancies during crises. And as we responded in one of the villages, we met with a woman who spoke to our clinical team and said, "You know, I really don't want to have another baby. I am going through so much with the family, losing our house and having to start all over again, I really do not want to have another baby for the next five to 10 years. Is there anything available that you can actually help me to prevent pregnancy?" Because as she stated, she would have to pay $800 just to hire a fiberglass boat to travel from her village to access the services at the hospital that was still functioning. And luckily enough, the team had taken with them contraceptives, and part of that were the intrauterine devices as well as implants. And what they were able to actually provide the woman with the choice of whether she would like to have an implant, or inter uterine device, and she actually chose to have the intrauterine device, she said, I really cannot afford to have another child. Because we really are going to have to work on building our homes again and even with climate change, there was so much happening. And all she said was, "thank you so much for thinking about us. Because as a woman, I get to think about my husband and my children, what we like to see them, how are we going to survive the next day. And when you are able to think this for me, and so grateful that an organization like RHFA is able to do this for the women."
Dr Lara Andrews 12:39
That's really interesting. And you've highlighted in a challenge that is particular to the Pacific with there being so many archipelagos, and remote islands that during the health emergency, what stood out for me was that the access to services became incredibly unaffordable, like you mentioned $800 for a boat just to have a safe delivery. And that that almost becomes untenable for women. So that does sound like an incredible challenge for being able to deliver services during health emergencies, particularly where roads or travel routes are cut off. So Gillian, listening to my talk and some of the issues that she highlighted about the challenges and and the obstacles of being able to provide sexual reproductive health services during health emergencies, and particularly during disasters or complex settings where services are disrupted, roads are blocked. What is your experience from the work that you've done in Africa? Can you share some examples of where there have been challenges and some of the ways that providers have worked around them?
Gillian McKay 13:51
Right, thanks so much for the question. Yeah, I think great answer from Ma, really interesting and it brought up so many, so many parallels to the work that that I've done in Sierra Leone and the Congo. And so I think what really struck me was the when she said about the example of the one who said, "now's not a really good time to have a baby like, I don't want to have a baby right now. I need to wait". And my research has says had have exactly the same kind of comments about, "Ebola time is not a good time to have another baby". The economy often has suffered severely women have lost access to income, schools are often closed. And so women are very eager to to access a family planning option if there's one made available to them. In many cases, the women I spoke to were like, well, I've chosen to go with a natural family planning method. But that offers a real window opportunity that if we do offer women modern methods of family planning, whether that's an intrauterine device, implants or other options, then we know that you know if they're well-messaged that there's potentially an option to take it out.
Other kind of challenges that are thrown up that are very similar are around the transport that Ma mentioned, the work that I did in North Kivu in the Congo, that is a kind of long standing protracted conflict setting where you had and then an Ebola outbreak on top of that very complicated environment where transport was very restricted, all of a sudden, the cost for getting to hospital went, just absolutely skyrocketed, very similar to what Ma was saying. So, you know, in terms of identifying opportunities for that it's about working with local taxi firms and working with local transport authorities to identify, okay, pregnant women are very much an essential, essential travelers and they need to have access to hospital, we can't be breaking that that chain or that link. But it's about very much engagement with policymakers because a lot of these decisions are brought down a little bit from on high in the middle of an outbreak. Okay, we've got to stop movement, because that's how we stopped Ebola transmission. It's like, yeah, but we really got to think about what are the kind of again, those external consequences or the secondary impacts that happen as a result of these types of policies.
Dr Lara Andrews 16:16
So I guess my next question that I'd like to ask to both of you, and and to hear from you, from your different perspectives, by Gillian, from you, from your research and your work in Africa, but also from you, Ma, and you're on-the-ground experience in Fiji. Do you think that sexual reproductive health and rights are being prioritized in the way that they should be during health emergency responses and planning?
Gillian McKay 16:43
I think it's a great question. And and one that I think the answer is no, unfortunately. Not that there aren't really great policy frameworks out there, both from WHO, and as my mentioned, from the Interagency Working Group on Sexual Reproductive Health, they've got the minimum initial service package. So there are really good frameworks out there for how to prioritize Sexual Reproductive Health in these types of crises. But unfortunately, in my experience, from working in outbreaks, we, policymakers health facilities, health systems tend to get very tunnel-visioned on stopping the outbreak at all costs, it becomes the overarching priority. And again, kind of harking back to what I said a few minutes ago, that means that policies that are put in place, we don't think about the secondary impacts of those policies on things like sexual reproductive health. So whether that's transport restrictions, whether that's redistributing health care workers from providing routine, sexual reproductive health care, or any kind of health care, really, they get moved, okay, now you have to go work in the Ebola treatment center. But that means who's going to deliver that baby when a woman shows up to the clinic, if there's if there's no nurse or midwife there to provide that care.
And an example that I would bring up from from the Congo is that we identified that there's already reasons for women to delay getting access to good quality maternal health care, in labor, causing, unfortunately, morbidity and mortality for themselves and their babies. But in an ebola outbreak, these delays just become exponential. A woman has to decide, okay, I'm going to take myself to the clinic when I'm having a complication of labor. But you know, am I safe to go to the clinic? Am I going to get infected at the clinic? Am I going to have to pay huge amounts of money to get a taxi to get to the clinic? Because there's been all these restrictions put in place? When I get to the clinic? Are they going to think I have Ebola? And are they going to send me away for testing? And am I going to get good quality maternity care at an Ebola treatment centre? And none of these things are assured. And so these are kind of, you know, these are barriers that the outbreak policy framework puts in place. Not intentionally, I don't think it's malicious. It's unfortunately though, not well thought through because we're not prioritizing sexual reproductive health and rights in these kinds of contexts.
Dr Lara Andrews 19:04
So it sounds like what you're saying is because there's such a focus in stopping the outbreak, that sexual reproductive health along with other health issues gets left behind so whilst there's a policy framework for it, the reality of allocating resources can mean that these critical issues and services become left behind.
Gillian McKay 19:28
Yeah 100%. They become thought of as a nice-to-have, not a have-to-have. But you know, sexual health is not a nice-to-have. It is a requirement of everybody's kind of healthy lifestyle.
Dr Lara Andrews 19:45
Yeah, Ma, I'll turn to you now on this same issue and ask you your opinion or perspective on how you see sexual reproductive health being progressed, advocated for particularly during health and humanitarian emergencies and responses in the Pacific. So would be really interested to hear progress, as well as where some of the obstacles still are for the on-the-ground implementation. Thanks, Ma. I'll hand it over to you.
Matelita Seva-Cadravula 20:17
Thank you, Lara. It's true that one of the most important aspects of humanitarian assistance is often forgotten when disaster and conflict strike. And that is access to essential life-saving sexual and reproductive health services. I've been working in the area of sexual reproductive health and rights for over 10 years. And I'm happy to report that great strides have been made in both stable and humanitarian settings. In the Pacific, a lot of the progress we have made is attributed to the SPRINT initiative by the Australian Government. SPRINT stands for Sexual and Reproductive Health in Crisis, and Post-crisis settings. So the SPRINT initiative has been operating in six countries throughout the Pacific as part of the International Planned Parenthood Federation member associations. We are quite fortunate to be part of this initiative, putting sexual and reproductive health and rights on the agenda to increase capacity, especially to respond to humanitarian crisis. But there's still a lot more work to be done. And this was brought to the fore when COVID reached our shores. Initially, sexual and reproductive health services was not considered to be an essential health service so we had to close our clinics briefly. But after some advocacy, we quickly gain the recognition and consideration of being an essential service. As a result, during our most recent humanitarian response, the Government of Fiji invited us to be part of the Fiji Emergency Medical Assessment Team to Kadavu Island Group. Through this, we were able to build and create awareness on the importance of sexual and reproductive health in emergencies. But I totally agree with Gillian, when there is an infectious disease around the government tends to shift its priorities. Thank you.
Dr Lara Andrews 22:33
Ma. Thank you for that. And you did raise the issue of COVID. And I was very interested to hear from both of you whether or not we've seen seeing the same challenges play out with the response to the COVID pandemic. So Ma, again, I'll turn to you and ask you, it's great to hear the commitment from the Fiji government to integrating sexual reproductive health into their emergency assessments. I'm curious to hear what the situation is on the ground with the competing priorities of needing to resource a response with maintaining routine services, particularly those that are critical to sexual reproductive health. And so Ma for your sort of perspective of the on-the-ground, what's happening now, situation.
Matelita Seva-Cadravula 23:22
Thank you, Lara. As Gillian had already mentioned, once government shifts its priorities. When SRH or sexual and reproductive health is no longer a priority, we begin to actually look for ways in which we could actually advocate to government. So one of the things that we did was to see the many door-to-door services that we have to actually put in place so that we can reach our women. And this was part of the data that we actually presented to government to say, hey, sex is not stopping just because we have COVID pandemic. Our clients, they still need to have contraceptives, they still need to prevent unwanted unplanned pregnancies, and gender-based violence, especially sexual gender-based violence, it's still happening, and we need to provide these services. So it was quite a struggle, like I said, we had to close and there were not enough protective equipments, for the service providers. So there is a lot of obstacles when it comes to having a disaster within a disaster, having a pandemic and then we needed to do a response, because there was Tropical Cyclone Harold, but then, Government has shifted its priority to saying there is no movement. Even now in Fiji, we have curfew from 11pm to 4am. Then again, if our women will need to access the birthing units, they will need to hire a cab or even go call the ambulance, which is very costly. It's about $120 for about 10 kilometers, 10 to 15 kilometers, just to get to a Birthing Unit, a service that should be rendered to any woman who is giving birth and not having to pay for those services.
Dr Lara Andrews 25:41
And Ma, do you think that we'll see changes in the number of women who are accessing supervised deliveries as a result of these kinds of issues? And in particular, the restriction of movement?
Matelita Seva-Cadravula 25:52
Yes, Lara, I totally feel that there will be a change in that. But we are hoping with the the health centres that do provide in Fiji... we're quite fortunate because we have hospitals. And then we do have health centres that are there in the community. And we are hoping that the women are able to access those services, but of course, with restrictions and social distancing. And there is going to be an increase in women not having access to skilled birth attendants.
Dr Lara Andrews 26:35
That's a really important point about the unintended consequences of non-pharmaceutical interventions or social distancing. Gillian, I'm going to turn to you now after listening to Ma talk about experiences in Fiji. Can I ask what you're hearing from your networks about the impact of COVID on services in some of the locations where you've worked?
Gillian McKay 26:55
So I think what's what's been very interesting that we've been seeing is how COVID is being used both as a positive window opportunity and as a negative window opportunity. So depending on the agenda of a particular group, COVID can be used to restrict access to what we would consider in the sexual reproductive health space as essential service. I'm thinking here of safe abortion care. Some countries have used the opportunity of COVID to say, safe abortion care is no longer in essential service. Well, we know that if women don't have access to safe abortion care, they might very well choose to seek an abortion in an unsafe way, putting themselves at a very serious risk. So I mean, that's using COVID, to create kind of a negative window opportunity to change policy. But also, we're seeing it on the flip side, that some countries are saying, you know what? Because we can't provide care in a more traditional way of having women come to the clinic, we're going to do a pregnancy test and a scan if she wants a safe abortion. But we have these great new tools right now, like things like medical abortion, that can be provided by pills, we can mail that to her house after she's had a phone consultation with a doctor if she's not comfortable to come to the clinic or if the clinic has had to shut down because of local policy. So again, using COVID, to increase women's access to good quality reproductive health services in the midst of a very complex situation.
Dr Lara Andrews 28:22
There's a lot of global momentum around health security at the moment, what are the obstacles and opportunities to progress, sexual reproductive health and rights on the global agenda?
Gillian McKay 28:31
So I mean, I think there we've already spoken about a lot of obstacles and challenges that are very applicable to COVID. I mean, I think the the main one, for me is around competing priorities and the tunnel vision about where everything becomes about stopping COVID transmission to the detriment very much of sexual reproductive health. And how to get that back on the agenda is is a challenge. It really is. And I think a big part of this comes down to what we in the international development space called the humanitarian development nexus or the link between those two is that sexual reproductive health tends to be seen as a development issue. Whereas global health security and infectious disease outbreaks tend to be seen as a humanitarian issue. So you don't really have the same people in the room at the same time having the same conversation about how to prevent sort of secondary or unintended consequences.
So I think that's a really key point that we have to that we have to work on is about getting the reproductive health and rights and global health security people together to start thinking about how to plan together. COVID is not going to end anytime soon, unfortunately. We're looking at second, third, fourth, fifth waves probably over the next year. So we have a chance right now to get those people in the same room together to think about how to mitigate these negative impacts in future. So I think that's a really important opportunity that we have to take advantage of like now.
And I think that you know, another opportunity is that we can start to think about how to think how sexual health and rights is a broader issue than we often tend to think about as women's health and girls health. And COVID affects everyone. Not equally, we know that there are some groups that are very much more impacted. But how do we make sure that men, boys, LGBTQI groups, how are we including them in the sexual reproductive health and rights agenda in COVID? And, and we don't want to leave them behind. So again, I think let's take the time between these waves wherever we are in our various countries to plan better for all those groups.
Dr Lara Andrews 30:42
Thanks, Gillian, some really important messages there. Ma, I'll turn to you and ask you what do you see as the opportunities in the Pacific at the moment for progressing sexual reproductive health or to keep it on the agenda?
Matelita Seva-Cadravula 30:53
Thank you, Lara. I guess in the Pacific, we know that sexual and reproductive health is a key life saving intervention in humanitarian settings. And the provision of sexual and reproductive health services in crisis settings, saves lives, reduces suffering and maintains human dignity. So we are getting better at taking our learnings in stable times. And adapting to what we can do in emergency. I guess that brings, that brings into the discussion, the nexus that Gillian was talking about between development and humanitarian settings. Also, there needs to be a lot of work that needs to be done in terms of getting sexual and reproductive in emergencies discussed during stable times. And this needs to get into our emergency preparedness plan. So that we know that this are integrated into the policies. And this policies will not only remain as policies, but will trickle down into the implementation and become a standard operating procedure that whenever there is any disaster or any pandemic, we can actually draw on the standard operating procedures, whereby sexual and reproductive health would not have to be moved, because the priority has shifted in trying to address the the pandemic that may come into a country.
We need to work with policymakers. We need to work with policymakers in advocating so that they see the need to integrate sexual and reproductive health in emergencies into the policies that they will draw together. And this is one of the things that we are currently doing in Fiji is advocating with our National Disaster Management Office, as well as our Ministry of Health, Ministry of Women, Ministry of Youth. Youth engagement is important. In many times, we do not bring young people to the table. And we are always talking. The adults are always doing the talking and engaging and thinking that we know what our young people need. So these are important aspects. But we need to work with policymakers, because sexual and reproductive health in emergencies needs to get in the important documents that are there in-country. Vinaka.
Dr Lara Andrews 33:32
Thank you for those very clear messages for progressing sexual and reproductive health. Gillian and Ma, I'd like to thank you both for everything that you have discussed during this conversation. You have both highlighted how critical and important sexual reproductive health is, particularly in health emergencies, you have given us examples of how real the impact of a health emergency or humanitarian disaster is for women and men requiring services. And you have both highlighted that while there has been progress, and there is opportunities, there is still a lot of work that needs to be done. And Ma, I think your your very final point there, that the work is really with policy makers to get sexual reproductive health into the agenda to have the thinking done, not just during a health emergency or humanitarian disaster, but to have the full planning on sexual reproductive health and how it will be managed during those critical times. And so I'd like to finish off by thanking you both for your contributions and the very interesting examples that you have brought to this conversation with us and look forward to continuing to hear about the progress that you're both advocating for sexual reproductive health and rights during health emergencies. Thank you to you both.
Gillian McKay 35:01
Thank you so much. It was a pleasure.
Matelita Seva-Cadravula 35:02
Thank you, Lara.